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resident Trump’s proposed budget chops $6 billion, about a fifth of the total budget, from the National Institutes of Health, a move that could decimate biomedical research in a number of areas and stagger academic institutions around the country that depend on NIH grant money to keep their scientific research programs afloat.

Research funding at the Department of Energy and the Environmental Protection Agency would also take steep cuts under the budget blueprint, released early Thursday.

The budget for the National Science Foundation isn’t specifically listed but it likely falls under the category of miscellaneous agencies targeted for across-the-board cuts of nearly 10 percent.

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As for the pharmaceutical industry: Trump has repeatedly promised drug makers he’ll make it easier and cheaper for them to bring new medicines to market, but he’s also counting on them to pay more for their regulatory reviews. His budget calls for hiking the fees that industry pays the Food and Drug Administration to review medical products, arguing that companies “can and should” pay their fair share. Trump aims to bring in  $2 billion from these user fees in 2018, approximately double the current level.

Funding for the NIH has been a bipartisan priority for years; one of Trump’s key advisers, former Representative Newt Gingrich, has long championed that cause. It was just two years ago, in fact, that Gingrich called for doubling the NIH budget, calling health spending both a moral and a financial imperative. “It’s irresponsible and shortsighted, not prudent, to let financing for basic research dwindle,” Gingrich wrote then.

But Trump’s $1.1 trillion budget reflects new priorities in D.C.: The Pentagon, Department of Homeland Security, and Veterans Affairs would all get significant boosts in funding, offset by sweeping cuts across other domestic spending. The EPA and the State Department would be hardest hit, with each taking cuts of about 30 percent.

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The Department of Health and Human Services comes in for a cut of more than $15 billion, or nearly 18 percent — a figure that includes additional funds for “program integrity and implementing the 21st Century Cures Act.”

Trump has talked often about the need to address the opioid crisis; his budget calls for a $500 million increase in spending to increase access to treatment and recovery services.

Natalia Bronshtein/STAT Source: GPO: Budget of the United States Government

Trump’s budget proposal, which is slim on details, is just a blueprint; the details will be negotiated with Congress, and top Republicans have already made clear that they’re not on board with all the cuts. Just this month, Representative Tom Cole, who chairs a key appropriations committee, told STAT he hoped to boost NIH funding by as much as $2 billion this year. (The agency got its first significant budget hike in years, of $2 billion, in late 2015.)

And within hours of the blueprint’s release, Senator Roy Blunt (R-Mo.), who has also called for increasing NIH spending, issued a statement calling the president’s plan just the “first step” in a long a process. “There are many concerns with non-defense discretionary cuts,” Blunt said.

Senator Bernie Sanders went further, calling the budget “morally obscene.”

Advocates for scientific research, too, fired off sharp criticism. The proposed budget would “cripple” science and technology “through short-sighted cuts,” said Rush Holt, CEO of the American Association for the Advancement of Science.

“Biomedical research is not something you can toggle on and toggle off,” said Dr. Landon King, executive vice dean of the Johns Hopkins School of Medicine. “The disruption and uncertainty this introduces into the progression of existing work or the initiation of new work is extraordinarily threatening.”

Though the details are sure to change, the budget document is important nonetheless in laying down a marker of the president’s priorities.

At the NIH, for instance, the plan calls for a “major reorganization” of the 27 institutes and centers that make up the agency. It outright abolishes the Fogarty International Center, which spends $69 million a year to support research on global health and encourage collaboration between health research institutions in the US and in other nations.

The Fogarty center pushed back immediately on Twitter with a link to a page that lays out its funding for everything from Alzheimer’s research in Colombia to HIV treatment in South Africa to an effort to model the spread of infectious diseases.

Trump’s budget is quite vague on other spending targets in the realm of health and medicine.

There are no specifics listed for the Centers for Disease Control and Prevention, for instance, beyond a pledge to create a $500 million block grant fund to help states respond to their specific public health challenges. It’s not clear if that’s new funding or if it would be reallocated from elsewhere within the CDC. The budget also talks about unspecified investment in “mental health activities” such as suicide prevention.

Also mentioned in the document, without specifics: A plan to create a “federal emergency response fund” to address public health emergencies such as Zika.

The plan calls for “consolidating” the Agency for Healthcare Research and Quality, which among other things provides evidence-based guidelines for clinicians. It’s not clear whether, or how, the agency’s work would continue.

The budget doesn’t mention specific funding levels for Medicare and Medicaid, though the Republican health care bill moving through Congress would enact significant cuts to Medicaid spending.

Among the few specifics in the HHS budget blueprint: Trump would eliminate $403 million in funding to train health professionals and nurses, calling the program ineffective.

It proposes a modest increase, of $20 million, in the Department of Housing and Urban Development budget to mitigate health hazards such as lead-based paint in homes.

President Trump’s proposed budget

Dylan Scott and Megan Thielking contributed reporting.

Correction: A previous version of this story misstated the budget for the Fogarty International Center.

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  • Well…its not like there is no legitimate point here. There is alot of pointless spending on basic research by NIH because: 1. duplicate research projects/objectives/focus occurs and even in the same research institution, and 2. no actual infrastructure demanding/enforcing proof that published findings are even reproducible (it is a prediction that 2/3 basic science publications contain false information).

    So providing less access for money may “cut the fat” as other commentators have mentioned. I can’t really say that this is an unprincipled move.

  • There is great potential angst over changes in the NIH budget. It is clear that NIH and academia seeds the innovation ecosystem.
    https://www.linkedin.com/pulse/technology-diffuses-from-academic-lab-seeds-ecosystem-mike-helmus

    Any large organization has “fat” than can be reduced. Here we need an appropriate and factual assessment to determine how to maintain our ability to drive innovation in a cost effective manner. This may suggest a study by the National Academies.

  • Thanks for the summary. Check the Fogarry figure tho ($69 million I believe, not billion).

    And NIH already does a lot of what AHRQ does, as does PCORI. There are some health lobbyists who say it’s different, but outside of the USPSTF, the research goals are certainly duplicative.

    • What, specifically, does AHRQ do that NIH does already?

      NIH funds a lot of basic science research, like what enzyme X or gene Y does. AHRQ is really quite different. It might fund research on whether there is evidence that drug A and drug B, which operate on enzyme X, differ in effectiveness from observational data. It might fund research on the effect of incerased market competition on insurance generosity. That’s health services research, which is about health systems work and how they can be improved.

      Either you know some specifics I do not, in which case I encourage you to share them, or else you don’t know the basic differences between the sort of science the NIH does and the sort of research that AHRQ does.

      Disclosure: AHRQ funded the first year of my PhD program. My program very rarely goes for anything NIH, we mainly get funds from AHRQ, for precisely the reason I outlined above: NIH does not address the sorts of questions we do. Again, I am very confident there is a significant difference in their missions, but I look forward to hearing any specific evidence you have to contradict that.

    • Hi Weiwen,

      Thanks for your comment – and for going into science.

      This isn’t really hard to find though. Just go to NIH RePORTER and search CER (effectiveness, not efficacy), or “health services” “health care delivery” “health care accessibility” and you’ll find the amount of funding on grants in this area exceed AHRQ’s annual budget authority in these areas. This isn’t about whether or not it’s worth funding that research. It’s about whether or not we need two organizational infrastructures to do so.

    • DCer,

      I did this. Many of the NIH grants related to “comparative effectiveness research” as a search term (which is the full term for CER, and which is what people interested in replicating this should search for) cover material that AHRQ grants would not. And yes, the NIH grants still tend much more towards basic research than the AHRQ ones.

      Yes, there’s overlap. For example, one NIH grant is a 3-arm randomized trial for nurse practitioners visiting at home, vs NPs plus community health workers visiting at home, vs usual care for stroke patients. I am pretty sure AHRQ might be able to fund such a trial.

      But, when you go search for AHRQ-funded projects related to stroke on their page, you will see grants like 1) the comparative effectiveness of various levels of rehab care for stroke, 2) impact of regionalization of care in stroke patients, 3) CER for warfarin vs dabigatran for preventing stroke in atrial fibrillation patients (using observational data), 4) a project related to economic modeling of various types of imaging technologies to detect stroke. 3) and 4) are things that NIH might fund. 1) and 2) are not. And when I go search NIH for comparative effectiveness and stroke, the projects there that are clearly related to what AHRQ might fund are in the mold of 3) and 4).

      https://gold.ahrq.gov/projectsearch/external_search_result.jsp?PAGE=2&QUICK=stroke

      And that’s just for things directly related to treating strokes. 1) and 2) are how system-level factors impact care for strokes. NIH doesn’t deal with those things nearly as much as AHRQ.

      PCORI does comparative effectiveness research, but it focuses on outcomes that are meaningful to patients. For example, total healthcare spending is something that matters a great deal to policymakers. But a patient doesn’t care what her total healthcare costs are per se; she cares about her quality of life, which is influenced a lot by whether or not her symptoms impair her life, or by her function. Outcomes like that are what PCORI focuses on.

      These different organizations have different focuses. NIH is focused on diseases, organ systems, and the basic science. AHRQ is focused on system-level factors that affect healthcare. PCORI is focused on studying and improving treatments’ impacts on outcomes that are directly important to patients, and often not directly important to policymakers.

      It’s not clear that you appreciate the differences between the missions of those 3 organizations. It’s not clear that you did anything more than search for CER on NIH’s site, tally up the grant totals, and say OK, this is more than AHRQ’s budget, without actually attempting to understand what the NIH grants deal with and what AHRQ does. You may have, but it’s not clear from your initial post.

      And you say that you aren’t addressing whether or not we should fund that research, you’re just wondering if it should all be funded under 2 or 3 separate organizational structures. You do realize that this whole proposal to consolidate AHRQ under NIH is contemporaneous with a proposal to significantly cut NIH’s budget, right? In that context, one has ample cause to wonder what you’re saying. For better or worse, administrative savings from consolidating NIH, AHRQ, and PCORI together and eliminating the things that are actually duplicative would barely move the needle on the federal budget; that’s not to say it might not be a bad idea to do that (although you then have to take on the management problems associated with that sort of consolidation).

    • Thanks for the reply. I’m a little concerned that you’re coming at it dogmatically rather than empirically. This is due to the fact that your argument demonstrates significant cognitive dissonance, while the data you present also refutes your arguments. Let’s take your research into NIH’s CER portfolio. With a tiny sample size of 4 AHRQ projects, you found that 50% would be germane to NIH’s portfolio. But, interestingly, you claimed that project 2. (impact of regionalization of care) is a topic that NIH wouldn’t fund. Yet NIH RePORTER identifies numerous projects from NIH on that very topic. Here’s one from NCI: This project seeks to:

      5R21CA118452; Project Aims: 1) Estimate the impact of increased market concentration on transaction prices, costs, and mortality rates for the Whipple procedure and colon cancer resections; 2) Estimate the impact of increased procedure volume on both inpatient mortality and costs per patient for these two procedures; 3) Use estimates from Aims 1 and 2 to predict the impact of regionalization of the Whipple procedure and colon cancer resections on mortality, costs, and prices; and, 4) Estimate the welfare impact of regionalization of these 2 complex cancer surgeries”

      A good project, no doubt, But exactly the type of grant you claim that NIH would never fund. So let’s be clear, NIH funds health services research. A good amount. That’s not a bad thing in and of itself. We desperately need this type of systemic inquiry. But your claim that NIH only does ‘basic science’ is truly stunning. It of course funds a lot of basic science, but as we knew and as we can see, it also funds a lot of other health research. In fact, in response to NIH’s trend to fund less basic science over the years, congress has annually included language in the budget report to put a hard floor under the amount of basic science that NIH must fund. The bottom line is that NIH funding is trending into areas that are less and less basic-basic science. This may not be detrimental in and of itself. If that’s where our nation’s top scientists are seeing the best proposals, then they should fund them. But it’s clear that your claim that NIH does only focuses on basic inquiry is misinformed.

      A second misconception that you state (implicitly in regard to your description of PCORI) is that NIH researchers don’t care about outcomes that are meaningful to patients. This, again, is jaw dropping and almost offensive to the thousands of NIH grantees that spend their research careers on translational research that will improve patient outcomes. One can easily find thousands of grants funded annually by NIH that are outcomes-driven, so I won’t seek to list any here.

      More interestingly, you haven’t put forth an argument for the status quo that makes programmatic sense from a PI perspective. Since the grants you chose to highlight demonstrate significant mission creep (as you recognized, albeit understated), I’m curious in finding out why you’d rather have the current arrangement when a consolidation would free up more resources for actual grants? And while 20% proposed cut to NIH is disturbing and I hope a non-starter on the Hill, consolidating AHRQ to free up more grant resources has been on the table for over a decade. So this is not contemporaneous at all.

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